Common Orthopaedic/Rheumatological Histories - …

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© 2014 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision Common Orthopaedic ...
Common Orthopaedic/Rheumatological Histories Presenting complaint

Exploding symptom

Lower back pain

Pain Site Onset Character Radiation Associated symptoms Timing Exacerbating/relieving factors Severity

Relevant system reviews

Associations Sciatica, stiffness/deformity, sciatica, incontinence, neurological symptoms

General Fever, night sweats, weight loss

Pain Site(s) Onset Character Radiation Associated symptoms Timing Exacerbating/relieving factors Severity Stiffness/swelling •Worse in morning?, how long for (30mins=inflammatory, 5mins=osteoarthritis) •Better or worse after exercise •Sleep disturbance •Loss of function

Orthopaedic

Muscular

GI/urinary •Incontinence Discitis Spinal fracture

General Fever, rashes, weight loss

Clues to differential

Differentials

Lumbar spondylosis and facet joint syndrome (lumbar arthritis) Lumbar disc prolapse

Neuro •Motor: weakness/wasting, incontinence •Sensory: pain, numbness, tingling

Red flags •Cauda equina: urinary retention/incontinence, faecal incontinence, bilateral leg pain, severe/progressive neurological deficit •Infection or cancer: age <16 or >55 years at onset, cancer, weight loss, fever, night sweats, injecting drugs, immunosuppression •Fracture: trauma •Spondyloarthropathy: EMS, night pain, worse with rest Joint pain/ stiffness/ swelling

Differential diagnoses Grouping

•Acute onset lower back pain •In paraspinal muscles, not central •Chronic episodic mechanical lower back pain •Backache related to standing/walking a lot/sitting in one place •Progressive stiffening •Acute onset while lifting/bending •Severe pain •True sciatica •Neurological symptoms e.g. weakness, numbness (usually L5/S1 distribution) •Fever and systemic upset •Risk factors e.g. injecting drug user •History of trauma •Sudden onset •Morning stiffness •Pain worse on rest

Rheumatological

Ankylosing spondylitis

Other differentials

Myeloma bone lesions Bony metastasis Paget’s disease Spondylolithesis Osteoportic vertebral collapse Non-orthopaedic/rhematological Pyelonephritis PID Pancreatitis AAA

Rheumatological

Rheumatoid arthritis

Rheumatological •Joints: pain, stiffness, swelling •Work down body: skin (rashes, ulcers, raynauds), hair loss, eyes (redness, dryness), mouth (dryness), chest (breathlessness, SOB), GI (IBD symptoms), GU (discharge)

Gout

Psoriatic arthritis

SLE

Enteropathic arthritis

Orthopaedic

Osteoarthritis

Septic arthritis

Other differentials

•Slowly progressive symmetrical polyarthritis •Small joints (commonly of hand) •Deforming •Early morning stiffness •First MTP joint most commonly affected •Isolated swollen, hot, painful joint •Hyperuricaemia risk factors e.g. diuretics, alcohol excess (esp beer), renal disease •Associated skin plaques and nail changes •Early morning stiffness •Many patterns of joint involvement •Systemically illness with intermittent fevers •Photosensitive rash •Generalised myalgia and arthralgia •Other systemic Sx (e.g. psych disturbance, pleurisy, ulcers) •Symmetrical arthritis of lower limb joints and SI joints •Early morning stiffness •Symptoms/diagnosis of Crohn’s or UC •Elderly •Worse on movement (rest helps) and at end of day •Isolated hot, red, swollen joint •Agonizingly painful •Systemically unwell with fever

Single joint Traumatic (dislocation/fracture/ligament injury) Haemophilia haemarthrosis Pseudogout Joint specific problems (e.g. knee – chondromalacia patellae, OsgoodSchlatter’s disease, patellar tendinitis; hip – avascular necrosis) Adhesive capsulitis Transient synovitis Bursitis Reiter’s disease Multiple joints Viral polyarthritis (flu, HIV, hepatitis, rubella) Other connective tissue disorders e.g. systemic sclerosis, polymyositis, polyarteritis nodosa Other spondyloarthropathies e.g. ankylosing spondylitis, Reiter’s disease, Behcet’s syndrome, juvenile chronic arthritis Rheumatic fever

© 2014 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision

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